Abstract

Objective: This study aimed to investigate and compare the effects of tubular gastroesophageal anastomosis and traditional gastroesophageal supra-arch anastomosis on the postoperative lung function of patients with esophageal carcinoma.

Methods: A total of 90 patients with middle-lower segmental esophageal cancer admitted in our hospital from August 2014 to August 2016 were recruited to our study. They were randomly divided into two groups. The observation group underwent tubular gastroesophageal anastomosis, whereas the control group underwent traditional gastroesophageal supra-arch anastomosis. Changes in the postoperative pulmonary function were compared between the two groups.

Results: The numbers of CD4 cells (27.45 ± 5.48), CD8 cells (35.97 ± 7.16), and natural killer cells (20.79 ± 2.49), as well as the CH4/CD8 ratio (0.69 ± 0.18), of the patients in the observation group were significantly higher than the (38.45 ± 5.98), (20.45 ± 6.41), (39.44 ± 3.49), and (1.31 ± 0.48), respectively, of the patients in the control group. The differences between the two groups were statistically significant (P<0.05). By contrast, the preoperative forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and maximum voluntary ventilation (MVV) did not significantly differ between the two groups (P>0.05). The FEV1 (1.76 ± 0.41 L), FVC (2.33 ± 0.32 L), and MVV (33.7 ± 5.2 L/min) of the observation group were significantly higher than those of the control group (P<0.05). Meanwhile, the complication rate of the observation group was 42.2%, which was significantly lower than that of the control group (75.6%) (P<0.05).

Conclusion: Tubular gastroesophageal anastomosis can benefit patients with esophageal cancer by significantly reducing the adverse effects on their postoperative pulmonary function and control the occurrence of postoperative complications.

Keywords

Introduction

The traditional treatment for middle–lower segmental
esophageal cancer is mainly gastroesophageal supra-arch
anastomosis [1]. This operation often results in pulmonary
hypofunction and variable complications, which seriously
affect the prognosis. Meanwhile, tubular gastroesophageal
anastomosis is a modified operation based on the traditional
gastroesophageal supra-arch anastomosis [2,3]. The majority of
clinical studies have demonstrated that the latter surgery can
significantly reduce the negative changes in postoperative
pulmonary function, as well as the postoperative
complications, of patients with esophageal cancer [4]. This
study aimed to investigate and compare the effects of tubular
gastroesophageal anastomosis and traditional gastroesophageal
supra-arch anastomosis on the postoperative pulmonary
function of patients with esophageal carcinoma.

Materials and Methods

General information

A total of 90 patients with middle–lower segmental esophageal
cancer admitted in our hospital from August 2014 to August
2016 were selected. These patients included 66 males and 24
females aged 26-72 years, with an average age of 55.4 ± 7.3
years. Among these cases, 50 presented with lesions in the
middle segment and 40 in the lower segment. A total of 73
cases were squamous carcinomas, 17 adenocarcinomas, 16
stage I tumors, 56 stage II tumors, and 18 stage III tumors. All the patients were diagnosed by pathological examination and
electronic gastroscopy. They were randomly divided into the
observation and control groups, with 45 cases in each group.
No statistical difference was noted in the general data
(P<0.05).

Method

The procedures of the radical resection of esophageal
carcinoma were consistent between the two groups. Tracheal
intubation and intravenous general anesthesia were adopted for
anesthesia. In the observation group, the stomach was
dissociated at least 5 cm away from the distal end of the tumor
below the gastric cardia. Then, the lesser curvature was
dissociated from the third branch of right gastric artery. The
lesser curvature and cardia were removed with a stitching
instrument, and the right gastroepiploic artery was selected as
the nutrient vessel. The left gastric artery, short gastric artery,
left gastroepiploic artery, and right gastric artery proximal
branch were severed. A tubular stomach of 4-5 cm diameter
was created through the aortic arch esophageal bed. Lastly,
gastroesophageal end-to-side anastomosis was performed
through the left thoracic apex. In the control group, the
stomach was dissociated at least 5 cm away from the distal end
of tumor below the gastric cardia. The cystic stomach was
crossed over the aortic arch. Then, gastroesophageal end-toside
anastomosis was performed through the left thoracic apex.

Comparison of lung functions between the two groups
before the operation and in the postoperative 1 month

The preoperative FEV1, FVC, and MVV of the patients in the
two groups were not significantly different P>0.05). By
contrast, the FEV1 (1.76 ± 0.41 L), FVC (2.33 ± 0.32 L), and
MVV (33.7 ± 5.2 L/min) of the observation group in the
postoperative 1 month were significantly higher than those of
the control group (P<0.05) (Table 2).

Group

Time

FEV1 (L)

FVC (L)

MVV (L/min)

Observation group

Preoperative

2.24 ± 0.34

2.93 ± 0.36

41.5 ± 5.7

Postoperative 1 month

1.76 ± 0.41

2.33 ± 0.34

34.7 ± 4.2

Control group

Preoperative

2.28 ± 0.40

2.93 ± 0.40

41.6 ± 5.5

Postoperative 1 month

1.34 ± 0.36

1.84 ± 0.36

26.5 ± 3.7

t

7.038

8.930

9.238

P

0.014

0.007

0.003

Note: t and P expressed the comparison between the observation and control groups in the postoperative 1 month

Table 2. Comparison of lung functions between the two groups before the operation and in the postoperative 1 month.

Comparison of the postoperative complications
between the two groups

The complication rate of patients in the observation group was
42.2%, which was significantly lower than that of the control
group (75.6%) (P<0.05) (Table 3).

Group

n

Pulmonary infection

Stomal leak

Gastroesophageal reflux

Complication

Observation group

45

2 (4.4)

1 (2.2)

16 (35.6)

19 (42.2)

Control group

45

3 (6.7)

1 (2.2)

30 (66.7)

34 (75.6)

Χ2

9.850

P

0.000

Table 3. Comparison of the postoperative complications of the patients between the two groups (n [%]).

Discussion

Esophageal cancer is a common malignant tumor with the
highest mortality rate. However, most patients are only
diagnosed in the middle and late stages of their disease. The 2
year survival rate is usually less than 15% [5]. Moreover, 90%
of esophageal cancer cases are undifferentiated or poorly
differentiated squamous carcinoma by pathological
examination. The malignancy degree of tumors with this
pathological type is higher than those of others and leads to
easy metastasis and recurrence. Hence, esophageal cancer is
difficult to treat [6]. Even so, with the development of modern
radiotherapy and chemotherapy techniques, patients with
esophageal cancer have attained survival benefits. A study
reported that the 5-year survival rate of patients with early
esophageal cancer reached up to 80% after radiotherapy.
However, the adverse reactions caused by radiotherapy also
inflict increased pain in such patients [7].

Surgical resection plays an important role in treating middlelower
segmental esophageal cancer. The surgical incision
should be reasonably set depending on the tumor location to
improve the resection rate of the lesion. The anatomical
relationship of esophageal carcinoma is distinctive. The
surgical approach through the left thoracic cavity can increase
the difficulty of anastomosis after tumor resection and may
also result in residual neoplastic foci [8]. Clinically relevant
statistics showed that about 15%-30% of patients with
esophageal cancer suffer from postoperative pulmonary
complications. Meanwhile, radical surgery for esophageal
carcinoma can reduce lung function and leads to a poor
prognosis, seriously affecting the patients’ quality of life. In
the present study, the FEV1, FVC, and MVV of patients with
esophageal cancer declined in the postoperative 1 month. This
result indicated that the radical surgery for esophageal cancer is
clinically important in lung function damage. The FEV1 (1.76
± 0.41 L), FVC (2.33 ± 0.32 L), and MVV (33.7 ± 5.2 L/min)
of the patients in the observation group were significantly
higher than those of the control group in this postoperative
period. Hence, tubular gastroesophageal anastomosis attained a
superior prognosis to that of the traditional procedure and
effectively reduced lung dysfunction. Reports showed that
relative to that in traditional surgery, the lung function after the
modified operation was significantly improved in the
postoperative 4 weeks [9]. This result was achieved because
the modified operation replaced the resected esophagus with a
tubular stomach, which is a reconstructed anatomical structure
with a similar physiological structure to that of the original segment removed. Moreover, the stomach space was not
expanded; thus, excessive encroaching of the thoracic volume
was avoided, and the lung was not compressed.

Esophageal cancer resection can damage the lower esophageal
sphincter, diaphragm crura, phrenoesophageal ligament, and
other structures that can effectively prevent gastroesophageal
reflux. Thus, esophagectomy easily leads to gastroesophageal
reflux [10]. In the present study, only 35.6% of the patients in
the observation group suffered from gastroesophageal reflux.
This proportion was significantly lower than that in the control
group. Thus, tubular gastroesophagostomy can significantly
reduce postoperative gastroesophageal reflux. This result was
attained probably because a major portion of the lesser
curvature was resected, the delomorphous cells were
significantly reduced in number, and gastric acid secretion was
hence controlled. Moreover, the size of the tubular stomach
was similar to that of the esophagus. The reconstructed
digestive tract was comparable to the physiological and
anatomical structure. As a result, gastric emptying was
promoted after eating and the food retention time in the chest
and stomach was reduced. No difference in the incidence of
two kinds of complications after esophageal carcinoma
resection (postoperative pulmonary infection and anastomotic
fistula) was observed between the two groups. Overall, the
incidence of complications in the observation group was
significantly lower than that in the control group. Hence, the
tubular stomach can control the postoperative complications
after esophageal cancer resection.

Conclusion

In summary, tubular gastroesophageal anastomosis can
significantly reduce the adverse effect of surgery on the
postoperative pulmonary function of patients with esophageal
cancer, as well as control the occurrence of postoperative
complications. As such, the procedure merits clinical
application.